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5 ^^ r?^.Te. 

{UNITED STATES OF AMElUCA.il 



INFANTILE PARALYSIS, 



AND ITS 



| 

ATTENDANT DEFORMITIES. 



BY 

CHARLES FAYETTE TAYLOR, M.D., 

RESIDENT SURGEON NEW YORK ORTHOPAEDIC DISPENSARY ; AUTHOR OF " ME- 
CHANICAL TREATMENT OF ANGULAR CURVATURE OF THE SPINE ;" 
"SPINAL IRRITATION, OR CAUSES OF BACK- ACHE AMONG 
AMERICAN WOMEN;" "THEORY AND PRACTICE 
OF THE MOVEMENT-CURE," ETC. 



PHILADELPHIA: 

J. B. LIPPHNTCOTT & CO. 

1867. 



Entered, according to Act op Congress, in the Year 1866, by 

CHARLES FAYETTE TAYLOR, 

In the Clerk's Office of the District Court of the United States 
for the Southern District of New York. 



Davies & Kent, 

Electrotypers and Stereotype)^ 

183 William St., N. Y. 



PREFACE. 



Notwithstanding the very great progress made of 
late years in medicine and surgery, there are still 
many forms of disease which have not yet received the 
careful study they require, and about which there is 
so little to be found in medical literature that the 
majority of physicians are practically excluded from 
profiting by the experience of others. 

A hundred cases of Infantile Paralysis occurring in 
the practice of as many different physicians, in different 
localities, without knowledge of each other, and per- 
haps each the only case of a lifetime practice, afford 
very imperfect opportunity for that careful, compar- 
ative observation which positive science requires, 
Hence the meagreness of the literature on this subject. 
Only when some enthusiastic "specialist" calls them 
from their hiding-places — few in a given locality, but 
many in community — is there afforded sufficient oppor- 
tunity for that consecutive and multiplied observation 
necessary for establishing facts and making deductions. 
As to the facts set forth in this book, there is scarcely 
chance for mistake ; if the deductions are erroneous, 



IV PREFACE. 

some keener mind will detect the error ; but, believing 
them to be true, the profession have a right to them. 
I only claim a faithful use of opportunity, and a 
careful, honest observation of facts. 

I wish to express my indebtedness to F. O. Earle 
M.D., of Chicago, 111., lately assistant in this Institution 
for the accurate drawings illustrating the text. 

If these pages are true, there should be, ten years 
hence, a smaller proportion of cripples than now dis- 
tress our sight ; and that such may be the case is the 
fervent hope of 



The Author. 



N. Y. Orthopedic Institution, 
1303 Broadway, Sept., 1866 



DN,) 

• ) 



INFANTILE PARALYSIS 



ATTENDANT DEFORMITIES. 



STATEMENT. 



Paralysis in early life is either the direct 
or remote cause of a large proportion of the 
distortions of the upper and lower extremities 
which afflict a certain number in every com- 
munity. 

Perhaps it is not always sufficiently realized 
that children of a tender age are as much 
more liable to loss of muscular power than 
persons of mature age, as they are to any 
other form of sickness. The young of every 
kind are always most susceptible and possess 
least power of endurance, and when not well 
guarded, suffer most from adverse influences. 
And this is especially true with regard to 



t> INFANTILE PARALYSIS, AND 

affections of the nervous system. Hence there 
is sufficient reason for the fact, that paralysis 
is of common occurrence in early life. 

DEFINITION. 

By the term ''Infantile Paralysis" I do 
not mean simply a paralysis occurring in 
infancy or childhood ; but I desire to restrict 
the use of the term — and it is so used in this 
paper — to indicate that form of paralysis 
which occurs only in infancy. Or if the 
same form of paralysis be found to occur after 
maturity, then the term should indicate that 
which occurs principally and characteristically 
in children. In fact, as will be hereafter more 
fully understood, I use the term to express a 
paralysis peculiar to the growing period. Per- 
haps, more correctly, it might be called the 
paralysis of nutrition and development. 

FREQUENCY. 

There seems to be no doubt that this disease 
is much more frequent now, and in this coun- 












ITS ATTENDANT DEFORMITIES. 7 

try, than > formerly, and is rapidly increasing. 
Nor is it difficult to account for this state of 
tilings. 

PROBABLE CAUSE. 

Modern, and especially American, civiliza- 
tion is characterized by peculiar activity of 
the brain, and this is often carried to great 
excess. 

The motive-force of American progress is 
brain-power. It is the ceaseless activity of 
directing mind that, in two centuries, has 
subdued the wilderness and peopled the 
continent ; that has built vast cities whose 
commerce reaches the remotest regions of the 
globe ; and that has proved itself capable of 
solving the most difficult political problems. 
The creative energy of the distinctively Ameri- 
can intellect is recognized everywhere. But 
such vast results of this creative intelligence 
have not been accomplished without some 
sacrifices. It has diminished our physical 
endurance. As a people, we are dyspeptic, 
and weak in bodily vigor in the inverse ratio 



8 INFANTILE PAEALYSIS, AND 

of over-activity of brain. Our laborers have 
to be imported. We are predisposed to 
nervous derangements. As a people, we are 
over-worked. The nervous system becomes 
exhausted, and a constitution less strong than 
our own, but more excitable and impressible, 
is transmitted to our children. 

WHY VIGOROUS PARENTS PRODUCE SICKLY 
OFFSPRING. 

It is often asked, M How is it that, when 
both parents are well and vigorous, the chil- 
dren are often puny and nervous Y 3 The re- 
ply must be, that the offspring partake of the 
parents' condition at the time they were hegotten. 
A man who is thoroughly engrossed in busi- 
ness calculations and cares, or even in the 
pleasures of society, will beget children with 
physical powers correspondingly subordinated 
to the nervous. To insure a perfect plant, it 
is not only requisite that the seed be pro- 
duced by a strong and vigorous tree, but 
no drought must have absorbed its sap or 



ITS ATTENDANT DEFORMITIES. 9 

untimely frosts have chilled it while the seed 
was maturing. We have imperfect grapes 
if an accidental cut lets the juice of the vine 
leak out. 

How, then, can even naturally vigorous 
persons expect to bear children of equal vigor 
if begotten while they themselves are ex- 
hausted with intense mental labors and excite- 
ments? It is a physiological impossibility. 
Hence our children are born with a surprising 
degree of nervous irritability ; just the temper- 
ament for the production of infantile paralysis 
when favorable circumstances combine to 
produce it. 

MOST COMMON AMONG THE RICH. 

And, as may be supposed, this disease 
occurs most frequently in the families of 
active business men. Indeed, while strumous 
diseases abound in the lower classes, I have 
seen but very few cases of infantile paralysis 
among them. My whole experience has led 
me to regard infantile paralysis as being 



10 INFANTILE PARALYSIS, AND 

almost confined to the families of active, in- 
telligent men, as above indicated. 

ITS PATHOLOGY. 

The definite pathology of infantile paralysis 
is not well understood. I have no theory to 
offer, and will only assume to present the facts 
connected with these cases which a pretty 
extensive, close, and prolonged observation 
of them may justify me in giving, with a con- 
siderable degree of explicitness. 

SYMPTOMATOLOGY. 

In many cases the paralysis is ushered in 
with symptoms apparently, in all respects, re- 
sembling inflammation of the membranes of 
the spinal cord. There may be every justifi- 
cation in applying the term spinal or cerebro- 
spinal meningitis to those cases. But there 
are many even among these severer cases, 
where the disturbance follows, rather than 
precedes, the paralysis, in such a relation as to 
suggest the inquiry, if the disturbance might 



ITS ATTENDANT DEFORMITIES. 11 

not possibly have been the effect, rather than 
the cause of it? So great a shock as the 
paralyzing of a portion of the body might well 
be expected to produce a profound impression 
and serious disturbance. 

CONSTITUTIONAL SYMPTOMS SOMETIMES TRIFLING. 

There are other cases, however, in which 
the constitutional symptoms are so trifling, as 
to tax our minds to account for them in 
connection with so serious and dangerous a 
disease as inflammation of the spinal cord or 
its membranes. Is it possible for distinctive 
inflammation to be going on in the brain or 
spinal cord, and the patient exhibit no 
symptoms which might point to it? And 
yet there are many cases of infantile paralysis 
in which there is no noticeable variation 
from ordinary health, the only symptom to 
be noticed at the very time, being the 
paralysis itself. 

CaseI. — K. G., at eleven months old, had 
learned to walk. Suddenly it was observed 



12 INFANTILE PARALYSIS, AND 

that she was unable longer to do so, and 
it was six or eight months later before 
she regained imperfect locomotive power. 
The right leg was partially paralyzed ; but 
there was no sickness or other indication of 
the cause, or even the time of its occurrence. 
At thirteen I operated on her for partial 
club-foot. 

Case 2. — M. D., though a delicate, nervous 
child, had no special sickness before or after 
the paralysis. One day, when two years old, 
she started to walk across the floor, but 
became paralyzed when she got to the middle 
of the room. The paralysis is in the right 
leg — not complete, though attended with 
partial arrest of development. 

Several other cases of paralysis without 
constitutional symptoms have come under 
my observation, though they embrace but a 
small proportion of the whole. But cases in 
which the symptoms are very mild are quite 
common. 

In some instances the child is put to 



ITS ATTENDANT DEFORMITIES. 13 

bed apparently well, and is found paralyzed 
in the morning, but without any indication 
of the time in the night when the paralysis 
happened, nor was the paralysis followed by 
any unusual bodily disturbance. 

GENERAL HISTORY. 

The majority of those cases, however, have 
about this history : the child is getting its 
first molar teeth — for the greatest number of 
cases occur when the child is from fourteen to 
twenty months old. Sometimes there has 
been a diarrhea, or other drain upon the 
S} 7 stem, or cause of irritation, accompanied 
with slight fever, though not often enough to 
keep the child abed. In a few days these 
symptoms abate and the child appears better ; 
but on making efforts to walk or use his 
limbs, it is found that he has lost the power 
to do so. In most cases, the exact time 
when the paralysis happened is never ascer- 
tained. - 



H INFANTILE PARALYSIS, AND 

SELDOM UNCONSCIOUS. 

It is seldom that the accession of this form 
of paralysis is accompanied with unconscious- 
ness. In one case, the child, in apparently 
perfect health, was sleeping quietly in its 
cradle, watched fondly by its father. It awoke 
with a scream, and was found to be completely 
paralyzed in its entire body. But neither 
then, nor at any subsequent time, was there 
any unconsciousness. It is true that there 
are occasional cases of convulsions followed 
by infantile paralysis,* but there are more 
cases of convulsions which are not followed 
by paralysis, and a careful study, when they 
do exist together, has failed to establish 
to my mind any direct connection between 
them. Any sufficient irritation may produce 
infantile convulsions ; but they do not seem 
to be caused by or to cause the paralysis, 
though the paralysis may happen at about the 



° Infantile apoplexy, with convulsions and paralysis, is quite 
different from that which we are now considering. 



ITS ATTENDANT DEFORMITIES. 15 

same time. As a general rule, this paralysis 
in young children is accompanied with much 
less severe symptoms (though this is not 
always the case) than when the patient is 
older. With increase of years, the accom- 
panying symptoms in general become more 
pronounced, and are neither so sudden in their 
accession, nor do they pass so speedily away. 
A child from ten to fourteen years old may 
be sick for several months with a more 
gradual and less uniform accession of paralysis. 
This is often accompanied with severe symp- 
toms of what is generally called spinal or 
cerebro-spinal meningitis. 

PECULIARITY OF INFANTILE PARALYSIS. 

But the form, rather than the origin, of 
this paralysis is to engage our study. 

I wish to call attention to the idea before 
alluded to, viz., that there is a form of paral- 
ysis peculiar to the growing period; that it is 
most likely to occur at the times of greatest 
organic or vegetative activity; and that it 



16 INFANTILE PARALYSIS, AND 

ceases to act after the organs have attained 
complete maturity. The periods of life dur- 
ing which it is most liable to occur are from 
six months to four years of age, and again 
from ten to fourteen. This form of child- 
hood-paralysis has peculiarities not found in 
other forms, whether these other forms occur 
in children or adults. Children as w^ell as 
adults may have apoplexy, softening, inflam- 
mations, blows on the head, etc. ; but the 
resulting paralysis is always essentially differ- 
ent from that which we are now discussing. 

NO EVIDENCE OF CENTRAL LESION. 

One essential feature of infantile paralysis 
is. that there is uniformly perfect recovery, so 
far as we can discover, of whatever disease of 
the nervous center — if it is ever really caused 
by a local lesion — which may have caused it. 

THE DISEASE PERIPHERIC. 

Another essential characteristic of this pa- 
ralysis is the entire absence of reflex irritability 



ITS ATTENDANT DEFORMITIES. 17 

of the muscles, accompanied with a remark- 
able diminution of capillary circulation in the 
affected parts, and a correspondingly diminish- 
ed muscular power. These, and the arrested 
growth of certain parts, are the only remain- 
ing evidence of previous disease. If we can 
conceive of a general constringing of the capil- 
lary vessels, and a shutting off of the capillary 
circulation, with such a physical condition as 
would result if the limb had for a long time 
been tightly bandaged, we should gain a very 
good idea of the actual condition in infantile 
paralysis. In fact, my own belief is that the 
disease is essentially peripheric, and that the 
great nervous centers are only indirectly and 
secondarily implicated. On no other hypoth- 
esis can I account for all the phenomena 
of these cases. But whether this suggestion 
be the true solution or not, the essential con- 
dition in infantile paralysis is a cutting off of 
the capillary circulation and a corresponding- 
loss of muscular irritability ; the latter to a 
great extent, if not wholly, due to this depri- 



18 INFANTILE PARALYSIS, AND 

vation of blood in the small vessels. And the 
limb withers as does a plant when the chan- 
nels to its irrigation are dried up. It is a 
well-known physiological fact, that the func- 
tion of any organ is diminished or destroyed 
by cutting off its supply of blood, and a muscle 
can no more act without its supply of blood 
than it can act without the nervous stimulus. 
In other words, you may paralyze a muscle 
as completely by stopping its circulation as 
by dividing its nerve. And it appears to me 
that the only satisfactory explanation of all 
the facts in these cases, is to suppose that 
the paralysis is nearly, if not wholly, due to 
the diminished capillary circulation rather 
than, as in other forms of paralysis, to the 
direct influence of a lesion in the brain or 
spinal cord. By what precise pathological 
condition this withdrawing of a large part of 
the sanguineous fluid is brought about, I 
have no theory to suggest. There is no 
doubt as to the fact, however. 



ITS ATTENDANT DEFORMITIES. 19 

TENDENCY TO RECOVERY. 

There is another fact of immense import- 
ance, and that is, that these cases all tend 
toward recovery. Very few cases are to be 
met with where some portions of the origin- 
ally paralyzed members have not entirely 
recovered. Of course, there are cases so bad 
that the sufferer must always remain without 
hope of essential improvement. Still, the 
large majority of all the cases I have seen 
had more than twice the paralysis when it 
occurred, or when it was first discovered, 
than they had at the end of the first year. 
One arm or leg may be paralyzed, but 
no other portion of the body affected. But 
more frequently the patient who comes to 
you a year after the attack, w r ith a single 
paralyzed arm or leg, was at first paralyzed 
in both legs or over the whole trunk and 
extremities, but has recovered except as 
to some single member. If the recovery is 
complete, it generally takes place within a 
few weeks, or at furthest a few months. And 



20 INFANTILE PARALYSIS, AND 

it is a curious circumstance, that this spon- 
taneous recovery of a portion of the original 
paralysis is as much more complete in certain 
members as it is more imperfect in the re- 
maining ones. That is, in cases of paraplegia 
for instance, if there is very great improve- 
ment or complete recovery in one leg, the 
other will improve but very little ; while, if 
both legs improve alike, the result will be 
more general power than in the worse leg, and 
less power than in the better leg in the first 
case ; as though nature possessed only reserve 
force enough for the complete recovery of one 
member, or a less relative improvement if this 
force be divided between the two. But na- 
ture, immediately after such a shock, is seldom 
capable of repairing the whole damage which 
has been inflicted. She does with comparative 
rapidity what she can, and would often do 
much more if permitted. Many a theory has 
been triumphantly established by happening 
to be tried at a time when nature is sure to 
be using her reserve force to repair damages, 



ITS ATTENDANT DEFORMITIES. 21 

and always with more or less success. If 
the apostles of "electricity," "movements," 
11 strychnia," the "ice bag," etc., have no 
better data than partial recovery in a few 
cases within the period of first recuperative 
effort, their claims rest on a very unsatisfac- 
tory basis. I have said in substance, that 
there is a period of reaction during which time 
recuperative effort is carried forward with 
complete, or at least partial success. The 
partial recovery may be either as to the 
amount in all affected members, or com- 
plete in a portion, while recuperation has 
but slightly advanced in others apparently 
no worse originally than the restored por- 
tions. But why does the reparative pro- 
cess stop half way ? Evidently because na- 
ture may have exhausted her reserve force. 
But why should this reparative effort stop so 
entirely ? Why should we not expect, in ac- 
cordance with the analogy of all recupera- 
tive processes, a continuous, though retarded 
improvement ? While the fact is, that after a 



22 INFANTILE PARALYSIS, AND 

certain time improvement is very feebly mani- 
fested and very slight in nearly all cases, while 
in many the condition of the remaining 
paralyzed limbs actually grows worse as time 
passes ; averaging perhaps one case with 
another, a total cessation of improvement 
after the first few months. But I think it 
can be very clearly established, that when 
patients do not continue to improve beyond 
a certain point, or when the improvement is 
so feeble as only to be recognized from year 
to year, as well as when there is no longer 
any improvement to be seen, that it is not 
always because nature has wholly exhausted 
herself, but because accidental circumstances 
have come in to interfere with her work, 
which would otherwise have gone on much 
further. 

" CONTRACTIONS." 

It is noticed that what are called " contrac- 
tions" of various muscles, accompanied with 
Mieir inevitable results, distortions of joints — 



ITS ATTENDANT DEFORMITIES. 23 

begin to appear early in the history of the 
case. And these so-called contractions go on 
till the distortions become permanent de- 
formities. When the contractions have pro- 
ceeded to a certain extent, all increase of 
muscular power ceases, and the case is gener- 
ally considered fit only for the orthopaedic 
surgeon. The question arises, " What is the 
cause of these contractions ?" They occur 
with a preponderance of certain forms ; that 
is, talapes varus is more common than talapes 
valgus, and contraction of the hamstring 
muscles are more common than relaxation of 
the same ; but there is the absence of all 
uniformity or law in reference to it. Certain 
contractions are most frequent simply because 
circumstances more frequently favor them 
than others, and not at all because the disease 
itself predisposes particular muscles to con- 
tract. I have used, and shall continue to use, 
the word " contractions" in the ordinary way, 
because the term sufficiently conveys the idea 
of shortened muscles ; but I do not by its 



24 INFANTILE PARALYSIS, AND 

use intend to accept the common idea of 
active contractions of the muscles, in which 
sense it is generally used. 

NO REFLEX CONTRACTION. 

It is just here where this form of paralysis 
differs so radically from all others — from those 
forms where there is a known lesion in the 
nerve- center. When there is a rupture and clot 
in, or inflammation of, the brain or spinal cord 
or their meninges, the paralysis is always ac- 
companied by reflex movements of the muscles, 
rigidity, spasm, clonic spasm, pain, numbness, 
and other indications of disturbance of in- 
nervation. But in the form of paralysis under 
consideration — except, possibly, during its in- 
cipiency — there is a total absence of the least 
variation of innervation ; no difference in the 
quality or amount of muscular force is ever to 
be noticed from one day to another, or varying 
with physical or physiological disturbances. 
In a word, Infantile Paralysis is peculiar, in 
that it is characterized by unvarying want of 



ITS ATTENDANT DEFORMITIES. 25 

irritability , and this want of irritability is prob- 
ably the cause of, as well as the extent of, the 
paralysis. What it is that has deprived the 
muscles of their irritability, or has deprived the 
nerves of their power of imparting their stimu- 
lus to the muscles ; whether the origin was in 
the nervous centers or in the nervous periphery 
where the only evidence exists of anything 
wrong — are questions regarding which I am not 
prepared to express an opinion. My only 
object at present is to direct attention to the 
fact of the unvarying absence of irritability in 
the muscles themselves, and the want of the 
ordinary evidence of local disease anywhere 
in the brain or spinal cord, as the essential 
characteristic features of this form of paralysis. 

SHORTENING OF CERTAIN MUSCLES. 

11 What, then, causes the muscular contrac- 
tions, and consequent deformities, which so 
regularly follow as a seeming necessary con- 
sequence of infantile paralysis ?" I reply, 
without hesitation, that contractions and dis- 



26 INFANTILE PARALYSIS, AND 

tortions are not necessary consequences of this 
paralysis ; and, moreover, that these unhappy 
results are always and entirely preventable. 
Indeed, what seem to be contractions of 
certain muscles — generally the flexors — are 
not contractions at all, but simply a me- 
chanical shortening of muscles when their 
attachments are for a length of time brought 
nearer together. Furthermore, this tendency 
of muscles to adapt their length to the position 
in which they are for a time placed, is found 
to be much less in these cases than where 
there has been no paralysis at all. And, as 
might be supposed, the greater the paralysis, 
the less the shortening of flexor and other 
habitually relaxed muscles ; and, on the other 
hand, the less the paralysis, the more readily 
do these muscles assume a permanently 
shortened condition when the limb is kept for 
a time in such an attitude that the ends of 
the muscles approach each other ; and when 
muscles are not paralyzed, they become short- 
ened or elongated according to the accidental 



ITS ATTENDANT DEFORMITIES. 27 

position of the limb much more readily than 
when paralyzed. In case of hip-joint disease, 
for instance, a very short time will often 
suffice to cause certain muscles to become so 
much shortened as to require tenotomy. But 
in infantile paralysis, the shortening of certain 
muscles is not the first or principal damage 
done by improper and careless positions of 
the paralyzed limbs. 

LENGTHENING OF MUSCLES. 

The shortening, though the most noticeable, 
is not the first or worst complication which 
arises to arrest the progress of improvement 
and to set in train a series of conditions 
favoring the formation of distortions and 
deformities. Any position of a limb which 
allows the extensor muscles to become short- 
ened must inflict a worse damage on the flexors 
by keeping them extended till they lose their 
remaining irritability and become degenerated. 
Now, we have another fact connected with 
these cases when they have arrived at the 



28 INFANTILE PARALYSIS, AND 

stage of deformity, viz., this: the difficulty of 
treatment consists much less in relaxing the 
shortened muscles than in giving tone and 
strength to their antagonists — the lengthened 
and weakened ones. Indeed, it is this, in the 
destruction of all remaining muscular irrita- 
bility, and in many instances the destruction 
and entire loss of the substance itself of the 
expanded muscle, which constitutes the prin- 
cipal anxiety in treating this class of de- 
formities. As this important consideration 
has been many times neglected, if not entirely 
lost sight of, let us consider the effect of 
simple extension upon the power and func- 
tions of muscular tissue in its healthy state. 

PROPOSITIONS. 

In reference to this, the following are 
believed to be true, viz. : 

1st. To retain a healthy muscle in an 
expanded state for a certain length of time is 
to diminish or destroy its irritability and con- 
tractile force. 



ITS ATTEMDANT DEFORMITIES. 29 

2d. To extend a muscle while in the act 
of contracting, that is, to overcome it, is to, 
at once, destroy its irritability and force. 

A moment's reflection will call up ample ^ 
illustrations of the correctness of the foregoing ' 
statements. 

1. — A few months ago, Dr. Wm. H. Van 
Buren read a paper before the New York 
Academy of Medicine, on the successful treat- 
ment of spasm of the sphincter ani, by means 
of this principle of overcoming muscular 
action. His treatment for this most distress- 
ing disease is as efficacious as it is simple and 
speedy. By inserting the thumbs within the 
sphincter and placing the fingers on each 
haunch as fulcrums, by a powerful effort he 
stretches the hypertrophied muscle to the 
fullest extent between the ischii. The irrita- 
bility and hypertonicity of the sphincter is de- 
stroyed and the cure is thus effected. I have 
seen several cases of relaxed muscles, and one 
case of real club-foot, which had been caused 
by a violent extension of muscles while in the 



30 INFANTILE PARALYSIS, AND 

act of contracting, which had from that moment 
caused paralysis of those muscles. 

THE " INDIA-RUBBER MAN." 

* " There is a curious illustration of the 
effect of extension on the ligaments and mus- 
cles now in this city. At one of the minor 
theaters there is exhibiting what is called the 
"india-rubber man" — an individual whose 
business it is to contort himself in the most 
unheard-of and inconceivable manner — dislo- 
cating his joints, laying his leg up along the 
spinal column, and otherwise defying ordinary 
anatomical laws. How did he attain this re- 
markable flexibility of joints and relaxation of 
muscles ? Muscles and ligaments are for the 
purpose of holding the frame together, rather 
than of facilitating its separation. I have 
been informed that every day this man 
subjects himself to a process of continuous 



* From my paper on " Tenotomy," in the N. Y. State Medical 
Society's Transactions for 1865. • 



.ITS ATTENDANT DEFORMITIES.. 31 

stretching of the muscles. A heavy weight 
is tied to the foot, which he holds pendent, 
slowly swinging in the air. The same is done 
to the arms and the whole body. The result 
is an almost complete destruction of the 
tonicity of the muscles and a corresponding 
relaxation of all the tissues. The muscular 
power is so overcome, and he is so nearly 
paralyzed, that he can hardly walk ; he is 
wholly incapable of a firm embrace ; the 
spinal column can be made to reverse the 
natural curves, and, altogether, he is an illus- 
tration on a large scale of what must and 
does occur in a single muscle or group of 
muscles when subjected to continued or 
violent traction or extension. The only 
possible results, loss of irritability and de- 
generation, are sure to follow. It might be 
inferred, and such is the fact, that the effect 
of extension is greater in the paralyzed 
muscle than in the healthy tissue, and that a 
slight degree of continuous or comparatively 
feeble sudden extension, which might be harm- 



32 INFANTILE PARALYSIS, AND 

less in healthy muscles, may be capable of 
destroying altogether the feeble irritability 
and power of a recently paralyzed muscle. 

1 ' The fact that continuous extension has 
the power of diminishing, and ultimately 
destroying, the contractility of muscles, may 
be explained without supposing rupture of 
the fiber-cells, when we remember that 
the course of the muscular fibrillae is not 
straight but zigzag, and that in contraction, 
this eccentricity is increased, the fibers being 
thrown up into irregular zigzags. In pro- 
longed extension, these eccentrics may be 
destroyed and the spaces closed up by the 
presence and pressure of other straightened- 
out fibers. Instead of a wavy mass, the fibers 
may approximate straight lines with a loss 
of some of the most essential features of 
muscular tissue and a corresponding loss of 
contractility. 

"It is no doubt already correctly inferred, 
that I place much more importance on the 
loss of power in certain muscles as explained 



ITS ATTENDANT DEFORMITIES. 33 

above (a relative loss of power beyond the 
primary effect of the original paralysis), than 
on the shortened condition of certain other 
muscles — their antagonists — which is usually 
referred to as the cause of these deformities." 

DIFFERENT DEGREES OF PARALYSIS IN DIFFERENT 
MUSCLES. 

Nothing is more noticeable than the vary- 
ing degrees of paralysis in different extrem- 
ities of the same individual, and indeed in the 
same limb. It is true of these cases, that 
there may be complete loss of contractility in 
muscles receiving their nervous supply from 
the same nerves, and even in contact with 
other muscles evincing considerable muscular 
power. There is no other explanation of this 
apparent defiance of all known physiological 
laws than the one I have given. But as a 
matter of fact, these variations — this relative 
losing or gaining of force — correspond exactly 
in all cases with the position of the muscles, 

whether they have been kept in extension or 

2* 



34 INFANTILE PARALYSIS, AND 

relaxation ; for muscles allowed to relax — all 
other things being equal — gain as much as 
the extended ones lose. The muscles kept 
in a shortened position, recover irritability 
more readily than if kept extended to their 
natural length ; but having no extension, 
become in time inelastic and tendonous ; 
while those kept unnaturally extended, lose 
their irritability and become thin and de- 
generated. 

And having thus destroyed the harmonious 
action of the muscles, as well as their length 
and mechanical adaptation, we have the first 
elements of a deformity. 

POSITION THE SOLE CAUSE OF SHORTENING AND 
RELAXATION OF MUSCLES. 

Having shown that position of the limbs 
alone is sufficient to cause deformity even in 
the healthy subject, it only remains to inquire, 
"Is this actually the case in infantile pa- 
ralysis ?" The reply must be affirmative. 

The particular steps toward the production 



ITS ATTENDANT DEFORMITIES. 35 

of deformity subsequent to an attack of 
infantile paralysis are simple enough. Sup- 
pose there is an attack of infantile paralysis 
during the period of extreme loss of mus- 
cular power ; the mere weight of the feet 
is more than the flexors can resist, and 
they are therefore drawn out. If the patient 
be abed, the position of the feet is that of 
extension — the toes droop by their own 
weight. This dropping down of the foot 
is aided — if not anticipated and provided 
against, as it ought to be — by the ordinary 
handling of the child ; the lifting and the 
friction of the heel against the mattress as 
the child is placed in bed under the covers ; 
and thus it is kept up till talipes equinus is 
actually produced. 

Fig. 1 represents talipes equinus after the 
foot has been used in locomotion. And 
when recovery begins to take place, the first 
feeble return of contractile power in the 
flexors is resisted and overcome, while the 
extensors, already in a shortened position, 



36 INFANTILE PARALYSIS, AND 

finding no resistance, assume permanently a 
shortened position. Now, what is the result 
from this beginning? 




Fig. 1. — Talipes Eqtjinus. 
FORMATION OF VARIOUS DEFORMITIES. 

The position of the other muscles up to this 
time may not have been sufficiently unnatural 
to cause much variation of force in them. 
But when the patient has regained sufficient 
strength above the feet to begin to use the 
legs, he can not use them, because he has no 



ITS ATTENDANT DEFORMITIES. 37 

perfect feet to stand on. The destroyed 
flexors of the feet let the toes drop to the 
floor, and the shortened extensors hold them 
there. He is thus forced to sit, unable to 
make use of the power he has up to this time 
recovered in the legs above the ankles, 
because of the deformity of the feet oc- 
casioned from want of care, to prevent the 
relaxation of the gastrocnemii muscles. Not 
till after the patient begins to sit, do we usually 
find shortening of the flexors of the legs and 
thighs. And thus sitting inevitably sets agoing 
renewed conditions favoring, and if persisted 
in, compelling, lengthening of the extensors 
and shortening of the flexors of the legs and 
thighs. There are seldom other deformities 
than the simple, equal extension of the 
flexors of the foot, and shortening of the 
flexors of the legs and thighs, while the 
patient remains in bed or only sits. But if 
he progresses still further, and begins to 
stand and walk, either the paralysis is so 
slight that the attitude of standing forces out 



38 INFANTILE PARALYSIS, AND 

and lengthens the shortened muscles ; and, 
relaxing the extended ones, allows them to 
regain their lost power, and the patient 
recovers more or less perfectly ; or, as often 
happens, the tendo-Achillis will not yield, 
the patient is thrown off the balance in efforts 
to sustain himself ; the foot is twisted and con- 
torted," and we get variations from talipes equi- 
nus, which has existed up to this time. The 
lateral muscles of the foot, already partially 
overcome by their position, are forced out, as 
the ankle twists to one side or the other ; 
and we have talipes varus, valgus, and other 
complications. If but one leg is paralyzed, it 
is most frequently talipes varus ; but if both 
legs are affected, it is generally talipes varus 
on the side where the extensors of the knee 
are weaker, and valgus on the side of the 
stronger leg. The limping to relieve the 
weaker leg throws an increased weight on 
the originally better leg in such a way as to 
overcome what were and would have re- 
mained the stronger muscles, and we have 



ITS ATTENDANT DEFORMITIES. 



39 



as a result talipes valgus (see fig. 4), and 
weakening of the hamstring muscles — results 
opposite from the first tendency. Fig. 2 
very well illustrates this idea. This peculi- 




Fig. 2. 



arity of locomotion often actually converts 
what was, and should have remained, the 
stronger foot and leg into the more deformed 



40 INFANTILE PARALYSIS, AND 

and weaker. For talipes valgus, though not 
so unsightly, is not so readily cured as talipes 
varus. 

The same general cause may also produce 
the knock-knee (either alone or in connection 
with the other deformities), and other com- 
plications. So that to cure a talipes varus 
of one foot, will often go far toward relieving 
talipes valgus of the other foot. Of course, 
we may have the same form of talipes of 
each foot, but then it is usually varus. 
In general, it may be said that all talipes, 
except equinus, are produced after the patient 
begins to bear weight upon his feet, and are 
caused by the impossibility, in most cases, of 
standing with shortened tendo-Achillis and 
talipes equinus. The ankle bends down in 
the direction of least resistance, which is 
most frequently outward — overcoming and 
elongating the tibialis- anticus and posticus 
muscles. In other words, talipes varus is the 
first effort of attempting to stand ; while 
talipes valgus is generally brought on later 



ITS ATTENDANT DEFORMITIES. 



41 



by walking. But in some cases, placing the 
child too early on its feet may at once 
destroy all contractility of the extensors of 




Fig. 3.— Talipes Varus. 

the foot, and talipes valgus, or at a later 
period talipes calcaneus, may be the result. 

The last mentioned deformities — talipes 
valgus and calcaneus — most frequently occur, 
for the reasons above given, on the least 
affected leg in paraplegia ; or if but one leg 



42 INFANTILE PARALYSIS, AND 

is affected, and either of these deformities 
follows, there is generally less paralysis, 
except as to the foot, than when followed by 
equinus or varus. In a word, the limb is 
strong enough above the ankle to have more 
weight thrown upon it to support. Fig. 4 
represents talipes valgus, and fig. 5 talipes 
calcaneus. 





Fig. 4. — Talipes Valgus. Fig. 5. — Talipes Calcaneus. 

It is thus seen that these several deform- 
ities of the foot — which are often the direct 
cause of other deformities at a distance from 



ITS ATTENDANT DEFORMITIES. 43 

the extremities — are entirely accidental in 
their origin, the worst form of talipes even 
occurring on the least paralyzed leg ; the 
paralysis being the occasion, but not the 
direct cause, of these deformities. I have 
dwelt on the manner in which club-foot 
is produced in these cases, because it is the 
first to appear, and is the most conspicuous. 
The other distortions of the limbs come on 
later, because the conditions favoring their 
production are less constant and are generally 
entirely wanting for a long time after the 
accession of the paralysis ; being deferred 
often till after the deformities of the foot have 
become a fact largely influencing the forma- 
tion of the other distortions. As the patient 
recovers, if he can not walk, or walks with 
great effort and imperfectly, he must sit a 
great part of the time. Hence, after a while, 
shortening of the flexors of the thigh and leg 
begins to be manifest, with the inevitable 
relative diminution of irritability and strength, 
and finally degeneration of the quadriceps 



44: INFANTILE PARALYSIS, AND 

extensor of the leg and even the glutei. It 
does not take but a slight flexion at the 
several joints to cause a deviation from the 
equilibrium and the throwing of the osseous 
framework off its balance, when the whole 
weight is thrown on the muscles and liga- 
ments. These give way in various directions, 
producing a sad catalogue of deformities. 

THESE DEFORMITIES ARE ALWAYS PREVENTABLE. 

If I have stated nothing but the facts — anc 
I have simply told my experience, begin 
with no theory and anticipating no conclu- 
sions — it follows as an inevitable corollar} 
that the deformities ordinarily attending infantile 
paralysis are entirely preventable! I do not 
say that the paralysis itself is always curable ; 
but, that the distortions generally following 
it are not a necessary consequence of the 
paralysis, and need not exist with it; and 
they will' not exist if seasonable and proper 
precautions are taken to avoid the secondary 
injuries to which the peculiar condition of 



ITS ATTENDANT DEFORMITIES. 45 

the muscles renders them liable. In these 
cases no muscles contract ; they only become 
shortened after having been kept relaxed for 
a considerable time. The improvement, be it 
more or less, would be uniform if the flexors 
of the foot and extensors of the leg and thigh 
were not kept in an extended position till 
they had lost their irritability and force. If 
the feeble muscles and ligaments of the joints 
were not subjected to overwhelming strain, 
by bearing too early an injudicious weight, 
they would not give way under the first 
attempt at exercise, instead of being strength- 
ened by it — which they might be, if proper 
precaution were observed, 

TREATMENT OF THE PARALYSIS. 

The treatment of infantile paralysis in the 
early stages consists, for the most part, in non- 
interference with the recuperative efforts of 
nature. While the nervous system is com- 
pletely overwhelmed by a recent shock, no 
treatment (for the paralysis) is good treat- 



46 INFANTILE PABALYSIS, AND 

ment. The general indications of the case 
should first be attended to, of course. For 
many months, and till interrupted by the 
causes heretofore named, the tendency is 
toward recovery ; though this recovery is, or 
seldom would be, complete without appropri- 
ate aid, and not often even then. Still, as I 
have said, the natural tendency is toward 
recovery ; and let no one fancy that his pet 
remedy administered at this stage has effected 
the change for the better. He may deceive 
himself, but not those who have had experi- 
ence in these cases. 

We are to remember how little it may take 
to injure the enfeebled muscular tissue, and 
diligently guard the patient from possible 
harm — knowing the direction from which 
injury is most likely to come. To this end, 
first of all, the patient should have the feet 
protected from extension by their own weight. 
This can be effectually done by placing them 
on a kind of sandal or shoe, as shown in fig. 
6, for keeping the foot at a right-angle with 



ITS ATTENDANT DEFORMITIES. 



47 



Cie leg. A careful decumbency is sufficient for 
other muscles while the patient remains in 
bed. After a time, the reaction from the first 
prostration begins to take place, the febrile 




Fig. 6. 

symptoms subside, and all the bodily functions 
resume their usually healthful course, except 
the power of motion in certain extremities. 
Even here, there is generally some decided 
improvement. If one extremity continue 
paralyzed, others, which at first seemed to be 
equally affected, rapidly regain their usual 
strength. But in certain members, the pro- 
gress of amelioration is slow, and, may-be. 
not sufficient to be noticed under ordinary 
circumstances. 



48 INFANTILE PARALYSIS, AND 

RECUPERATIVE PERIOD. 

And here we arrive at a very critical 
period. A certain amount of recuperation 
has taken place with a corresponding amount 
of improvement in some, at least, of the 
muscles. How shall we keep up this re- 
cuperative process ? Every organ is strength- 
ened by the proper exercise of its function. 
Whatever power there may be in a muscle 
after a certain time, needs to be used in order 
to develop more. But there may not be 
enough for the purposes of locomotion or 
actual bodily use ; and to let what has accu- 
mulated remain inactive, is to enfeeble what 
force there is for want of use. On the one 
hand, there is the danger of breaking down 
the inadequate muscles by placing the whole 
weight of the body on them in premature 
efforts to walk ; a^d on the other hand, 
without effort the muscular strength will not 
continue to increase. 



ITS ATTENDANT DEFORMITIES. 49 

LEGITIMATE MUSCULAR ACTION. 

Evidently, then, we must contrive to afford 
the muscles opportunity to act within their 
capacity — alike avoiding inactivity or over- 
action — until their development has reached 
the point where they are capable of being 
made available in sustaining the weight of the 
body, and in locomotion. The muscles of a 
leg, for instance, may be capable of sustaining 
thirty pounds' weight, not only without injury, 
but with actual benefit ; when sixty pounds 
— the weight of the patient, perhaps — would 
cause it to break down. There is evidently, 
then, but one thing to do in such a case. We 
must furnish the muscle an exercise that shall 
not exceed its capacity. If thirty pounds be 
the extent of its force, thirty pounds must be 
the extent of its exercise. And not until the 
powers of the muscles have been developed, 
till they are equal to sustaining the weight of 
the body, should they be required to sustain 
it. There is no physiological principle more 
clear or simple. The leg of a paralyzed child 



50 INFANTILE PARALYSIS, AND 

in relation to its body may be compared to 
those of an infant called upon to support the 
trunk of a man ; they can not do it, and 
should not be allowed to attempt it till they 
Iiave grown equal to their load. - But every 
particle of latent force calls for use ; action is 
its life and growth ; and under these unusual 
circumstances we are called upon to furnish 
the opportunity for whatever force there is/ 
to act. 

MUSCULAR DYNAMOMETERS. 

This involves contrivances for the display 
and use of small amounts of muscular force ; 
to specimens of which the attention is now 
invited. These muscular dynamometers — for 
such they properly are — embrace the prin- 
ciple of local exercise, which is equivalent to 
a great saving of force, in having it under 
control and direction — as well as the one 
more particularly under consideration, viz. : 
the ability to detect and use minute — and 
without such facilities inappreciable — quan- 



ITS ATTENDANT DEFORMITIES. 



51 



tities of muscular power. Fig. 7, for exercis- 
ing the flexors and extensors of the feet, is 
contrived on the principle of a balance ; when 




Fig. 7. 

the weight, W, is moved to one side or the 
other of the center, in the slightest degree, 
the force is opposed to the flexors or exten- 
sors of the foot ; and instead of supporting 
the whole weight of the body above, only a 
few ounces may oppose the muscles. 



52 



INFANTILE PARALYSIS, AND 



Figs. 8 and 9 represent contrivances on the 
same principle, but adapted to attain the 
same purposes with reference to the flexors 
and extensors of the leg. They all are 
reversible and unlimitedly adjustable. As 
the mechanical action of the different parts 




Fig. 8. 

of our locomotive apparatus varies at each 
joint, each contrivance must be adapted to 
its special needs. But the principle of making 
them all measures of force, and the means for 
using and developing the same, must remain 
the same throughout all. In the apparatus 
represented in fig. 10 the whole leg is used 



ITS ATTENDANT DEFORMITIES. 



53 



as in the very act of walking, but with any 

desired amount of force, from a few ounces' 

I 
up to more than the weight of the human 




Fig. 9. 

form ; and the contrivance is so arranged that 
as the limb is flexed the resistance is less, 
which increases as the limb is extended and 
stronger, so as to secure a steady, equal 



5i 



INFANTILE PARALYSIS, AND 



amount of effort in all positions ; the resist- 
ance being more when the leg is extended 
and stronger, and less when the leg is flexed 
and weaker. And so every apparatus for 




Fig. 10. 

giving exercise to a part must be adapted to 
the special mechanical arrangement of the 
member. If the patient has been carefully 
attended, so that no damage has been done 
by faulty positions while in a state of mus- 
cular atony, there will be no difference in the 
rate of recovery, nor will there be shortening 
or lengthening of different muscles, and the 
patient can begin to stand and walk at a 



ITS ATTENDANT DEFORMITIES. 55 

much earlier stage, and with much less 
strength, than when a very small amount of 
shortening of muscles has been allowed to 
take place. The reason for this is, that the 
least contraction of the flexor muscles will at 
once throw the patient out of his natural 
erect position, and the weight of the body 
must be held entirely by force of the muscles 
instead of resting on the bony framework, 
with only sufficient muscular aid to keep it 
erect. In other words, every joint will be 
slightly flexed with an impossibility of com- 
plete extension. If these " contractions" 
have already begun, the first attention must 
be paid to removing them ; and when they 
are recent and slight, extension of all the 
joints may be made, and the patient assisted 
to keep in the standing position by an 
apparatus represented in fig. 11. The move- 
able handles, C C, with the pad against the 
knees at A, controlled either by the patient 
or another, makes forcible or allows mus- 
cular extension at will. The position itself — 



56 



INFANTILE PAEALYSIS, AND 



when not obtained by too much effort — is of 
considerable value in aiding development. 
The simple, upright position, even when main- 




Fig. 11. 
tained without the aid of the muscles, seems 
to determine a certain amount of blood into 
the lower extremities — perhaps by gravity — to 
their decided benefit. And this leads us, by 



ITS ATTENDANT DEFORMITIES. 57 

a natural step, to consider here the import- 
ance of securing as complete a circulation in 
the paralyzed members as can possibly be 
obtained. It was observed in the first part 
of this paper, that the special peculiarity of 
infantile paralysis was that it was character- 
ized by a greatly diminished capillary circula- 
tion, making the loss of function due, at least 
to a certain degree, to thie cause. 

THERAPEUTIC VALUE OF WARMTH. 

All those who have had experience in these 

cases have recommended the warm or hot 

local bath as of great value. My experience 

is, that the value of local heat in these cases 

can not be over-estimated. It is a constant 

experience, that a limb which shows no sign 

of motion before, will generally give good 

evidence of awakened vitality after it has 

been immersed in a hot bath. It is an almost 

daily occurrence, that muscles which have 

remained for years, apparently, without power 

of motion, will evince contractile effort after 

8* 



58 INFANTILE PARALYSIS, AND 

the blood has been called into the inter- 
muscular capillaries by a high degree of heat. 
My plan is to apply the heat daily before 
beginning their exercises ; and in the first 
stages of the disease, the affected limbs should 
be kept not merely warm but actually hot, 
by means of heated bricks, bottles of hot 
water, etc. But a dry heat is very much 
better than the moist heat of a water bath. 
Moisture not only can not be borne at so high 
a temperature as dry heat, but it soaks the 
epidermis, making the skin sensitive, and 
preventing frequent repetitions ; once a day 
is all it can usually be administered. And, 
also, a large portion of the heat imparted by 
the water bath is carried off again in the 
subsequent evaporation from the surface and 
epidermis into which it has been absorbed. 
But a dry heat can be continued for hours 
and repeated at short intervals, besides being 
carried to a much higher degree. Parents 
are directed to prepare a screen large enough 
to protect the whole body of the child. This 



ITS ATTENDANT DEFORMITIES. 59 

is put before the fire, and the patient is 
placed behind it. Its legs are thrust through 
and placed on a bench very near the fire, 
where they are kept for hours at a time. 
The heat should be kept from the child's head 
and trunk, as we want not only positively 
but relatively high heat. A still more effect- 
ive plan is to place a gas-stove in a wooden 
box, one side of which is curtained with a piece 
of cloth having holes, through which the feet 
and legs are thrust into the box, where they 
are subjected to any degree of temperature 
desired. Nothing can be more easily regu- 
lated or more simple in its operation. 

NECESSITY FOR EARLY AND CAREFUL MANAGE- 
MENT. 

It is believed that if infantile paralysis 
were managed in its first stages on the plan 
above indicated, having in view the physiol- 
ogical indications and aiming at ultimate good 
results, there would be a much larger per- 
centage of recoveries than at present. My 



60 INFANTILE PARALYSIS, AND 

own cases — those in which I have had the 
good fortune to see them soon after the 
attack — have uniformly disappointed every 
one in the amount of their recovery. 

Case 3. — A single case will illustrate the 
principle. C. H. C, of Indiana, a lad ten 
years old, was brought to me in June, 1862, 
with paralysis of both lower extremities. 
The attack had only been five weeks previ- 
ously, and though it was a severe case, it 
gave me another desirable opportunity of 
conducting a case from very near the first 
according to my own ideas of treatment. The 
lad was large, active, intelligent — a usual 
characteristic in these cases — particularly 
precocious, with a rather slender physical 
organization. About five weeks before, on 
occasion of what was supposed to have 
been slight over-exertion, he was taken with 
symptoms usual with this kind of paralysis. 
There were a few days of febrile disturbance, 
which at first it was difficult to account for, but 
when the paralysis was discovered, was called 



ITS ATTENDANT DEFORMITIES. 61 

spinal meningitis. But whatever the cause, 
his bodily health was perfect when I saw him, 
and he had been brought a thousand miles to 
me without the least inconvenience. There 
was slight motion in the lower extremities, 
but utter inability to walk or stand ; the legs 
were diminished in size and lower in temper- 
ature than natural ; all the other functions 
were perfectly performed ; almost better, his 
parents thought, so far as appetite, digestion, 
and flow of animal spirits were concerned, 
than before the attack. His treatment was 
conducted on the principles and substantially 
after the plan set forth in the preceding 
pages. As he could not walk, he used to 
slide himself along upon his haunches by his 
hands, and it was fully two years before he 
could walk alone. But he did walk at last ; 
and for the past two years there has not been 
found a more active and enduring young 
person of his age and constitution in his 
native city (Richmond, Ind.) There is no 
dropping of the foot, twisting of the ankle, 



G2 INFANTILE PARALYSIS, AND 

weakness of the knees, or halt or limp to 
show that for two years and over he was 
paralyzed and not able to take a step ! But 
the point I wish to make in bringing this 
case forward is, that during all these two 
years of paralysis there were no so-called 
"contractions" with their attendant distor- 
tions and deformities of the paralyzed lower 
extremities ! If deformities are a necessary 
consequence of this form of paralysis, why 
did they not occur in this case ? They were 
not removed — had they been, the recovery 
would never have been perfect ; but they 
were prevented, by not allowing the condi- 
tions to occur which cause shortening of the 
muscles. Then why not prevent them in all 
cases ? I do not hesitate to say that I believe 
they might be thus prevented in all cases ; 
though I do not pretend that even to prevent 
deformity would in all cases be followed by 
complete recovery from the paralysis, though 
it would certainly increase the number of 
recoveries. 



ITS ATTENDANT DEFORMITIES. 63 

INJURY FROM DELAY. 

But it unfortunately happens that in the 
greater number of instances the orthopaedic 
surgeon does not see the case in the early 
stage of the disease, when he might advise a 
course calculated to prevent deformity and 
give the greatest chance of ultimate recovery ; 
but the patient is brought to him with not 
only paralysis, but paralysis accompanied 
with different forms of distortions of the 
affected limbs. He is not permitted to cure 
the case now, even if a cure at first had been 
possible ; but he must address himself to the 
removing, so far as possible, of the two-fold 
damage. It is now too late to think of 
radical cure ; hereafter he must labor long 
and anxiously to imperfectly repair what 
might have been much more easily prevented. 
But the slightest improvement in a child or 
young person who is to enjoy such improve- 
ment for a lifetime is to be diligently sought 
and gratefully acknowledged. 



64 INFANTILE PARALYSIS, AND 

TREATMENT OF THE DEFORMITIES. 

We come now to the means for removing 
the deformities allowed to be attendant on 
infantile paralysis. And even here the de- 
formity itself is not that which is the chief 
thought ; for although there is something 
very tangible in a club-foot, our surgery 
should come in to divide the shortened 
tendon for an ulterior object, the relieving 
and restoration of the flexor muscles. Our 
tenotomy should have quite as much reference 
to the lengthened as to the shortened muscles. 
And this is the secret — which should be no 
secret — of the frequent failure of tenotomy 
to effect that permanent benefit which it at 
first promised and seemed to afford. When 
no attention is given to the development of 
the antagonists of the shortened muscles, 
there is always danger of a recurrence of the 
same condition. It must occur again if the 
same causes continue to exist after, as before, 
the operations. Where there is but partial 
paralysis, and the shortening not extreme— 



ITS ATTENDANT DEFORMITIES. 65 

implying retention of a certain amount of 
force in their antagonist muscles — there may 
be spontaneous development of these weak- 
ened but not wholly exhausted muscles oc- 
curring too soon after tenotomy to allow of 
ultimately losing what is gained. But here, 
as in all cases, the tenotomy was but the first 
step — the loosening of the cords which pre- 
vented motion, and the development — which 
is the real cure — followed as a natural conse- 
quence. So that while our art of surgery or 
mechanics is applied directly to the tendons 
and muscles which resist the movements and 
bind up the parts in a distorted position, the 
real result — which does not make, but permits 
the cure — is the releasing the drawn out and 
weakened muscles. There are indeed in- 
stances when we are content to accept much 
less ; where, if the limb be straightened, that 
is all we hope to do. In such a case, the 
lower part of the leg is used by active muscles 
higher up, for purposes of locomotion, the 
same as a wooden leg would be, and it has 



G6 INFANTILE PARALYSIS, AND 

precisely the same use ; it is the bony frame, 
not the muscles, which is used. 

Observing that patients with paraplegia 
differed exceedingly in the apparent use of 
their legs — some with what seemed much 
greater paralysis appearing to surpass in 
powers of locomotion those retaining consid- 
erable muscular force — I was for a long time 
at a loss to account for this singular state of 
things. But it seems to be the fact, that 
where the paralysis is very complete, little or 
no shortening of the muscles takes place — as 
from the nature of the case we might on 
reflection see must be the fact — and the whole 
limb, or that part of it below the knee, is 
moved by the muscles attached to the trunk, 
which always retain much greater force — as an 
artificial limb would be. And if the leg and 
thigh are in the same perpendicular line, the 
weight of the body is easily borne on the 
osseous framework without the help of the 
muscles ; and, unless the toe is hit, or some 
cause should throw the knee forward, the 



ITS ATTENDANT DEFORMITIES G7 

patient can progress without much trouble. 
The foot is thrown far forward with a peculiar 
swing— especially peculiar when both legs 
are in this condition — and brought slightly 
back, and the knee pressed backward by 
leaning forward the trunk, so as to be sure 
that the knee-joint is fully extended. In 
general, the person has so often pressed the 
knee backward with the hand on rising from 
a chair and in other situations when he did 
not feel secure on his feet, that the posterior 
ligaments have been stretched till the leg no 
longer forms a perpendicular line, but curves 
backward. This enables him to make very 
good locomotion ; but it effectually prevents 
the slightest improvement in the power of the 
muscles after the moment the knee passes 
back of the perpendicular line of the leg. 

NECESSITY FOR CARE AND JUDGMENT IN THE 
USE OF MECHANICAL FORCE. 

The flexor muscles are extended and 
weakened by extreme extension, and the 



68 INFANTILE PARALYSIS, AND 

extensors are never excited to action — the 
motion at the knee, in such a case, being a 
mechanical one, effected by flexors of the 
thigh ; and hence they become degenerated 
for want of use. The same cause produces 
precisely the same result in the non-paralyzed 
muscles, as the following case will illustrate : 

Case 4. — A young girl had been treated for 
morbus coxarius by counter-extension. The 
treatment had been successful so far as to 
arrest the diseased action in the hip-joint ; 
but when she attempted to walk, it was found 
that she had almost no strength in the knee, 
and in that condition I first saw her. I 
found, on examination, both extensors and 
flexors of the leg with nearly complete 
paralysis, and so great relaxation of the 
posterior ligament and flexor muscles of the 
knee, that on extension the knee would be 
pressed some three inches back of the natural 
position. Hence the injury by severe exten- 
sion of the flexors and degeneration and 
atrophy from non-use of the extensors of the 



ITS ATTENDANT DEFORMITIES. 69 

leg, precisely as so often happens in infantile 
paralysis. It was ascertained, on inquiry, 
that, in effecting the counter-extension for 
relieving the hip-joint, the adhesive straps 
had been applied to the leg entirely below the 
knee, the attending physician apparently not 
suspecting that a force which could overcome 
the powerful muscles about the hip-joint 
would be liable to draw asunder the weaker 
muscles of the knee. This case did not, and 
could not, recover without aid, while the leg 
was used, because it was, from the nature of 
the case, self-continuing. It was cured by the 
same means employed for the same condition 
when preceded by infantile paralysis. This 
treatment consists simply in applying an 
apparatus with a stop-joint at the knee, which 
will entirely prevent excessive extension, or, 
indeed, will not allow the extension to be 
quite as complete as natural. If the ap- 
paratus is so adjusted that in standing the 
knee can not quite reach the perpendicular, 
that situation greatly stimulates the extensor 



70 INFANTILE PARALYSIS, AND 

muscles, which soon recover when there 
has been no paralysis ; and more slowly, of 
course, if the muscles have been previously 
paralyzed. The flexors also, kept continu- 
ously relaxed, soon begin to shorten accord- 
ing to the general law in such cases. 

INFLUENCE OF DIVERSE CAUSES. 

But this deformity (that produced by ex- 
tension) is less frequent than permanent 
flexion at the knee ; and when it does 
happen, it can nearly always be traced to the 
effects of oft-recurring over-straining, rather 
than to constant position. For instance, the 
talipes varus and flexion at the knee of one 
leg, which is originally the leg the more 
paralyzed, may cause talipes valgus and 
extreme extension at the knee on the other 
leg, which was originally but slightly affected, 
and would have entirely recovered but for 
these accidents. I say accidents, because it is 
owing to the crippled condition of the one leg 
that the weight of the body is constantly 



ITS ATTENDANT DEFORMITIES. 71 

thrown over upon the better leg in such 
a manner as to overcome the recovering, 
though still enfeebled muscles of the other. 
Thus we have produced talipes valgus by the 
extension of the peronei and gastrocnemius 
muscles. At the same time we may have 
knock-knee, or extreme extension of knee by 
relaxation of internal or posterior ligaments, 
as shown in fig. 2. 

This explains why we so generally find 
such strange disproportions in the location and 
degrees of weakness in different groups of 
muscles. There - is no deformity, however 
anomalous it may seem, that can not be 
accounted for in the operation of wholly 
preventable causes. 

We find on the side of weaker gluteii the 
stronger flexors ; and as we examine each set 
of muscles which acts in concert with others to 
produce a certain motion, there is never the 
same condition in the corresponding group of 
muscles in the two legs, nor in those co-oper- 
ating to produce combined movements in the 



72 



INFANTILE PARALYSIS, AND 



same leg ; this result having been produced by 
the purely accidental causes just explained. 



EXTENSION TENOTOMY. 

i In case there is flexion at the knee (fig. 
12), even when it is only slight, if the 




Fig. 12. 



strength of the muscles has been so weak- 
ened, either by the -previous paralysis or by 
subsequent persistent extension of the ex- 



ITS ATTENDANT DEFORMITIES. 73 

tensor muscles as to be unable to support the 
body, no attempt at developing these muscles 
will be at all availing until they have been 
liberated from their unnaturally drawn out 
position. This may be done either by divid- 
ing the tendons of the shortened flexor 
muscles or by extending them by mechanical 
means, when that is possible. In either case, 
and in all such cases, the object is to liberate 
the confined joint and allow of motion, in order 
that development, which has been stopped, 
may go on. In many cases it will not be 
found necessary to use the knife. But when 
tenotomy is resorted to, some contrivance for 
keeping up extension will be found absolutely 
necessary, in order to sustain the limb in the 
extended position until all the parts have 
become adapted to their changed position. 
Experience had taught me this. I noticed, 
as previously remarked, that persons with 
the knee bending slightly backward could 
walk, bearing their weight upon the leg, 
though there was little or no muscular 



74: INFANTILE PARALYSIS, AND 

power ; while a very slight flexion at the 
knee was always attended with utter useless- 
ness of the leg in spite of considerable power 
in the muscles. After vain efforts to develop 
sufficient force in the extensor muscles to 
sustain the body, I proposed to convert the 
forward into a backward bending at the knee, 
and adopted an apparatus (fig. 12) for that 
purpose. The difficulty of carrying the plan 
into successful execution did not depend so 
much on the resistance of the muscles as on 
the altered form of the knee-joint itself. 
After the posterior portions of the articula- 
tions have been in contact for a number of 
years, they become so altered that when 
weight is placed on the leg, the knee springs 
forward from the mere shape of the joint 
itself. This caused the necessity for a pro- 
longed use of the apparatus with the idea of 
continuing the contact of the anterior por- 
tions of the joint until time and use had 
so modified them that this difficulty should 
be removed. As the ultimate object was to 



ITS ATTENDANT DEFORMITIES. 75 

force extension so far that the knee should 

pass back of the perpendicular, the action of 

the apparatus was kept up in several cases 

for six months, and in a few cases even longer 

than that. The patients, rejoicing in the 

ability to use the leg — which they could on 

wearing the apparatus — and dispense with 

crutches, were careful to secure adequate 

« 
support by keeping up extension. 

RELAXATION OF EXTENDED MUSCLES CAUSES A 
RESTORATION OF IRRITABILITY. 

What was my astonishment and delight to 
find, in all cases, after a lapse of a few months, 
that the same extensor muscle which had 
before exhibited no power, had regained con- 
siderable contractility from having been kept 
a long time in merely a relaxed position ! 
However, this corresponds with other related 
facts in connection with these cases. But this 
fact alone, viz., the ability to restore, partially 
at least, an enfeebled muscle by persistently 
relaxing it, is of great consequence in the 



76 INFANTILE PARALYSIS, AND 

treatment and prognosis of these unfortunate 
cases. 

This history would not be complete with- 
out this concluding experience. 

Case 5. — One patient — a boy — had pro- 
gressed so far that he began to show consider- 
able power of extension at the knee, and could 
even take a few steps without the aid of his 
apparatus or crutch, when one of my asso- 
ciates, during my absence, made him an in- 
strument, like many used, allowing "a little 
motion" at the knee, with the not unnatural 
idea of " exercising the muscles." At each 
step there was a slight flexion at the knee ? 
and downward movement of the whole body, 
as its weight would overcome the muscles. 
The result was, much to his chagrin, that less 
than two months of this kind of " develop- 
ment" sufficed to destroy every vestige of 
power which the quadriceps extensor had 
previously acquired ! A return to the former 
treatment again restored the muscle to its 
former condition, and a continuance of the 



ITS ATTENDANT DEFORMITIES. 77 

treatment secured a continuance of improve- 
ment. The corollary to such experience is, 
that any " motion" which allows a muscle to be 
overcome is injurious to its contractile power.' 
A muscle knows no other "motion" than that 
which allows it to contract ! 

APPLIANCES CONSTRUCTED ON FALSE PRIN- 
CIPLES. 

It follows, then, that all those appliances 
with elastic straps, ostensibly to give ex- 
ercise to the muscles, but really allowing 
them to be overcome with a part, instead of 
the whole weight of the body — a difference 
which the muscles, so long as they are still 
overcome, must fail to appreciate — must be 
wrong in principle. If the springs are stiff 
enough to sustain the weight, then there 
might as well be no springs at all. Adjust- 
able stop-joints are better. The apparatus 
for extension at the knee is simply a stop- 
joint with a screw and knee-cap, as shown in 
the cut (fig. 12). But the extension must be 



78 INFANTILE PARALYSIS, AND 

unvaryingly persisted in till the ultimate 
object is reached. 

UNEQUAL ATROPHY OF DIFFERENT MUSCLES 
NOT CAUSED BY THE PARALYSIS. 

It must be seen that the variations in the 
relative strength, as well as the length of 
different muscles, do not depend on causes 
existing in the muscles themselves, or even 
on any peculiar condition of the nervous 
s} r stem or the nervous centers. As another 
illustration of the manner in which muscles 
may be injured by remote causes, take the 
following, which embraces a large class. Cases 
often occur like this : a child is attacked 
with infantile paralysis, and recovers, or is 
supposed to have recovered. But in a few 
years it is noticed that there is a peculiarity 
about the gait ; the child walks well enough 
on level ground, but is apt to stumble in 
rough places, and finally it is perceived that 
the leg is growing small above the knee / 



ITS ATTENDANT DEFORMITIES. 79 

INFLUENCE OF DISTANT CONTRACTIONS ON THE 
PHYSICAL MECHANISM. 

Examination reveals a slight shortening of 
the tendo-A chillis ; the heel does not quite t 
touch the floor in walking, and there is 
complete paralysis and atrophy of the quadri- 
ceps extensor of the leg. The fact is, that 
while the original paralysis lasted, a slight 
shortening of the extensor muscles of the foot 
had taken place — just enough to cause the 
ball of the foot to touch the ground before 
the heel — and a very little talipes equinus 
was the result. Acting as a lever, of which 
the ball of the foot forms one arm, the leg 
has been extended by the weight upon it 
without the aid of the quadriceps extensor. 
At every step the toes reached the ground 
first, and the knee is literally drawn back- 
ward by the tendo-Achillis, while the extensors 
of the leg are not allowed to act at all. The 
result is, that in process of time these exten- 
sor muscles become completely powerless and 
degenerated from want of use. Those muscles 



80 INFANTILE PARALYSIS, AND 

are much worse than if the paralysis had. 
been somewhat greater ; for, in that case, the 
talipes equinus would have been severe, or 
have been converted into a talipes varus, and 
in either case, by weakening the ankle, the 
backward action of the tendo-Achillis is lost, 
and the extensors of the leg would be obliged 
to act. As these cases — which are not rare 
— can walk well on ordinary ground, and only 
fail in certain situations ; and as the slight 
elongation of the foot just about compensates 
for the shortening in other locations, it is 
sometimes difficult to make the parents 
understand that the case can be cured only 
by making it temporarily appear worse. 

EQUALIZING MUSCULAR AND MECHANICAL POWER. 

For the first step is to lengthen — which is 
to weaken — the tendo-Achillis ; but this at 
once deprives the leg of its power of me- 
chanical extension at the knee until those 
extensors shall be increased in power suffi- 
cient to perform their legitimate functions. 



ITS ATTENDANT DEFORMITIES. £1 

The heel is let down — the leg is thus slightly 
shortened — so that, altogether, for several 
months there will be exhibited increased 
weakness and halting. But it is the only 
road to restoration, for if not counteracted 
there is danger of gradual increase of mal- 
positions and ultimate permanent lameness. 

To treat a case of this kind, if it be severe, 
the tendon may be divided ; but generally, if 
the shortening is not great, it can be over- 
come by an apparatus for producing exten- 
sion of the tendo-Achillis, worn at night only, 
but persisted in for months, and made to act 
very efficiently. (See fig. 11.) Of course, in 
connection with shortening of the tendo- 
Achillis there is always more or less feeble- 
ness of the flexors of the foot. I remember 
several cases when, after consultation, the 
parties were sent home w r ith no other advice 
than to keep up nightly extension with the 
simple apparatus with which they were pro- 
vided, when they returned after a number 

of months with very tolerable restoration of 

4* 



82 INFANTILE PARALYSIS, AND 

power in both extensors of the knee and 
flexors of the foot. But they must have the 
plan of treatment fully explained to them, 
and must also be of the most intelligent class, 
as it will be found difficult to make them 
pursue a treatment which, at first, causes the 
patient to be more lame and to appear worse 
from clay to day. But it will be found that 
as the vicarious extension decreases, the 
legitimate action of the true extensors of the 
leg will be stimulated, and in most cases the 
best result attained. 

I should say that it must be a very mild 
and simple case where extension during the 
night alone will suffice to lengthen the 
shortened muscles or allow the elongated 
flexors to contract. In most cases, an appa- 
ratus with a flexion screw, as shown at the 
ankle in fig. 12, is worn during the day ; and 
if the case is very bad, the same may be used 
at night also. Whatever the means, they 
must be made efficient. 



ITS ATTENDANT DEFORMITIES. 83 

TREATMENT OF TALIPES. 

With regard to the treatment of the differ- 
ent forms of club-foot which so generally are 
allowed to follow infantile paralysis, the same 
principle of treatment should be adopted 
as in distortions of other joints ; we extend 
or divide the shortened tendons in order to 
relieve extended and weakened muscles ; and 
we liberate the confined joints in order that 
motion and development may take place. 
The only difference between these deformities 
of the feet and those occurring in other locali- 
ties consists in their more complex nature, 
and consequently in the greater difficulty of 
adapting apparatus to the accomplishment of 
several different and distinct ends at the same 
time. But this task need not be so difficult 
as it is often made. 

When it is once understood that talipes 
equinus is the first, and simplest, and most 
natural sequence of the paralysis — the weight 
of the foot being all that is necessary to 
produce it — and that no other form of talipes 



84 INFANTILE PABALYSES, AND 

is likely to occur while the patient lies in 
bed ; and, moreover, that the bending of the 
ankle outward (varus) is the result of weight 
on a foot with a shortened tendo-Achillis ; 
and that bending inward (valgus) of the ankle 
is the result of weight partially overcoming 
the gastrocnemius, soleus, etc. ; and talipes 
calcaneus of weight entirely overcoming those 
muscles, it will be found that the nature and 
treatment of these deformities are capable of 
great simplification. (See figs. 1, 3, 4, and 5.) 
I have not alluded to the adductors and 
abductors of the foot — the tibiales anticus 
and posticus, and the peronei, because I 
believe their influence so exceedingly small 
in the formation of talipes that they need not 
necessarily be taken into account ; though 
once formed they exert a minor influence in 
maintaining the deformity. In talipes equi- 
nus and varus (figs. 1 and 3), the tendo-Achillis 
is shortened ; in talipes valgus and calcaneus 
(figs. 4 and 5), the tendo-Achillis is length- 
ened. On the other hand, the flexor muscles 



ITS ATTENDANT DEFORMITIES. 85 

of the foot are extended and powerless in 
talipes equinus and varus, and are shortened 
and active in talipes valgus and calcaneus. 
The production of the valgus and varus, 
though overcoming the internal or external 
lateral ligaments of the ankle and the peronei 
or tibiales muscles, as the case may be, must 
have either extension or shortening of the 
tendo-Achillis as a condition precedent. The 
extreme distortion of the^ foot itself, with 
the great alteration in form of the tarsal 
bones in some cases, are all secondary and 
subordinate matters, and disappear gradually 
when the causes producing them are reversed 
in time. The one essential fact which pre- 
ponderates in considering the principle to be 
kept in view in adapting apparatus to over- 
come these distortions — for every apparatus 
should be the exponent of an idea — is that the 
os calcis is the point which determines and hence 
controls talipes! Without a shortening or 
lengthening of the tendo-Achillis there could 
scarcely be a club-foot. And while we have 



8G INFANTILE PARALYSIS, AND 

to provide for all the sequences of these 
primary conditions, yet it should never be 
lost sight of, that the cause must be re- 
moved before the cure can be considered 
complete. 

APPARATUS FOR TALIPES. 

The apparatus which I have used for 
several years with great satisfaction, consists 
of a "night" shoe and a "day" shoe. The 
former is also worn during the day when the 
patient can not walk, and the latter is often 
worn at night instead of the night shoe. The 
first consists simply of two pieces of thin 
board — one for the sole of the foot, and the 
other and longer piece to pass up the back 
of the leg nearly to the knee. The rest 
consists of the various straps and the way 
in which they are adjusted. Much of the 
inefficiency of many of the shoes for club-foot 
arises from the defective manner of applying 
the straps. For instance, how can a strap 
which passes over the instep be expected to 



ITS ATTENDANT DEFORMITIES. 87 

resist the strength of the gastrocnemius, soleus, 
etc. ? Even after tenotomy, the pressure on 
the top of the foot is often unbearable, 
besides impeding the circulation. A better 
way is to pass the strap entirely around the 




Fig. 13. 

ankle (fig. 13), fastening it on the same side 
from which it started. Thus, in fig. 13, the 
straps, B B, start at the heel and pass above 
the os calcis around the ankle, just under* 
the malleolus, and fasten on the* same side 



88 INFANTILE PARALYSIS, AND 

and about three inches from the point they 
started from. The straps pass around the 
ankle in opposite directions. It will be seen 
that these straps, instead of pressing on a 
surface of only an inch or two in front of the 
foot, have their pressure distributed over 
more than the entire distance around the 
ankle. They also pass above the heel ; and 
besides firmly holding the ankle, they make 
direct traction on the tendo-Achillis by their 
downward action on the os calcis. By tight- 
ening the straps, C C, the extensor muscles 
are effectually antagonized. The strap A 
simply holds the top of the apparatus in place. 
This apparatus is just as effectual in 
either of the other forms of club-foot as in 
the variety just mentioned, all necessary 
variation of action being secured by a slight 
variation in the application of the straps. 
For instance, by placing the foot piece in 
contact with the sole of the foot, and allowing 
the leg piece to pass under the leg, as shown 
in the cuts, figs. 14 and 15, one strap, B B, is 



ITS ATTENDANT DEFORMITIES. 



89 



passed around the ankle, which is turned out 
as before, while the other, A A, is passed 
around the os calcis to act in the opposite 
direction ; while a third, C, holds the meta- 
tarsis in the same direction that the strap 
A A holds the os calcis. Now, if we draw 




Fig. 14. 



the strap D, the leg piece is drawn under the 
leg, and we have secured a most effectual 
and complete lateral action without the use 
of a spring or joint. If we now tighten the 



90 



INFANTILE PARALYSIS, AND 



strap E (fig. 15), as in talipes equinus, we 
have effectually antagonized both the lateral 
and posterior muscles, and have also the 
quality and degree of action entirely within 
our control. It is obvious that the same 




Fig. 15. 

apparatus will apply equally well to talipes 
valgus or varus, by simply reversing the 
action of the straps. For talipes calcaneus 
it is only necessary to supply the posterior 
strap, C (fig. 16), to make it a complete 



ITS ATTENDANT DEFORMITIES. 



91 



relief to the extensors of the foot and an 
antagonizer of the flexors. 

When these cases are taken at or near 
their early stages, especially before the tarsal 
bones have been subjected to the weight 







Fig. 16. 

consequent to walking, it only requires per- 
severance to accomplish a restoration of the 
equipoise between the different sets of mus- 
cles ; and this can generally be done without 
dividing them. But in long-standing cases 



92 INFANTILE PARALYSIS, AND 

we meet with great difficulty in the altera- 
tions and misplacements of the tarsal bones. 
In all such cases we are obliged to keep up 
the support, not only till relaxation of some, 
and retraction of other muscles, has restored 
a harmony of action, but also till the osseous 
structures have been brought back, by con- 
stant pressure in the right direction, to a 
natural shape and position. In this case the 
appliances just described, as they act prin- 
cipally on the muscles, would not be sufficient. 
We must use the same weight which was 
instrumental in forcing the osseous structures 
out of shape and position to bring them back 
again. The patient must walk ; and while 
walking he must have such appliances as shall 
not merely allow him to progress, but shall 
also convert what formerly was the means 
of forcing the tarsal bones out of shape, into 
the means of forcing them back to their proper 
position. No apparatus without a lateral 
action can do this. With a lateral deformity 
in talipes varus and valgus, it is necessary to 



ITS ATTENDANT DEFORMITIES. 



93 



meet, check, and reverse this tendency by 
lateral antagonism. The ankle brace repre- 
sented in fig. 17 is calculated to meet the 
indications in such cases. It consists of a T- 
shaped piece of steel, C, with the lower end 




Fig. 17. 

bent at right angles and passing under the 
sole of the shoe to which it is fastened. The 
cross piece is just below the malleolus, and 
from each end a strap, D D, passes around 



94 INFANTILE PARALYSIS, AND 

the ankle. Around the heel, but acting in 
the opposite direction, is the strap A, one 
end of which is fastened into the sole of the 
shoe, and the other, after passing around the 
heel, goes through the back of the shoe and is 
received by the slit, B, in the end of the 
curved steel piece, which is a continuation 
of C. At Gr is a joint allowing flexion and 
extension, and at H is a stop-joint regulated 
by a screw, I, which completely controls the 
lateral action of the joint. It will be seen 
that, as the straps D D and B B act in 
opposite directions, either by drawing these 
straps, or by the screw, I, we have the power 
of turning the ankle outward or inward at 
pleasure, and can convert the tendency to a 
talipes varus into that for talipes valgus, or 
the reverse, at once. As a practical matter, 
it takes much time and perseverance, careful 
attention, and a nice adjustment to keep the 
apparatus constantly in order till the form 
of the foot has been changed. The whole 
weight of the body resting on the apparatus, 



ITS ATTENDANT DEFORMITIES. 95 

and the distortion being resisted by it, it must 
be made exceedingly strong. It is never 
best to sacrifice efficiency to lightness. 

THE OS CALCIS. 

It will be seen that in all these appliances 
the os calcis may almost be considered as the 
helm by which the position of the foot is 
controlled. And when the correct position 
of this bone is secured and maintained a 
sufficient length of time, the other distortions 
of the tarsus will sooner or later disappear. 

CONDITION REQUISITE IN APPARATUS. 

Thus far I have spoken only of the me- 
chanical appliances which seem best to answer 
indications in the support of feeble joints; 
to counteract the effect of shortened mus- 
cles, and to relieve those whose position was 
destructive to their irritability and force. 
The main idea in these contrivances was to 
have them accurately meet the indications 
— whether of extension, relief, or support 



96 INFANTILE PARALYSIS, AND 

— and to see that they interfered with no 
other functions than those they were intended 
to aid or resist. Adjustability and efficiency 
must always be the grand object in the use 
of mechanical agencies. There must always 
be a principle of treatment which should be as 
closely followed in the use of mechanical, as 
in the use of any other therapeutic means. 

DEVELOPMENT, THE PRINCIPAL OBJECT. 

But even in these severe cases, when paral- 
ysis, time, and neglect of suitable preventive 
means have done their worst, we should still 
be actuated by the same idea in the hope of 
securing the largest amount of muscular de- 
velopment of which the case is capable. Al- 
though the mechanical treatment does secure 
advantages of its own, it arises from the fact 
that, by removing obstructions and protecting 
the distorted members from injury w T hile using 
them, there is a certain amount of spontane- 
ous development. This spontaneous develop- 
ment often, and in mild cases generally, 



ITS ATTENDANT DEFORMITIES. 97 

amounts to sufficient to complete the cure. 
But even in these cases the use of apparatus 
only prepares the way, by removing obstruc- 
tions, to the natural position of the parts, and 
allowing a natural action of the muscles. 
Development or increase of muscular power 
is the only source of lasting improvement 
after all. For, no matter how much or 
how often these distortions are overcome, 
either by surgical or mechanical means, 
they are sure to recur unless the con- 
ditions of paralysis and improper positions 
are removed. 

WHY DEFORMITIES RE€UE. 

No matter how often the deformity may 
have been cured, if the paralysis still exists, 
there will be a tendency to a recurrence of 
the same shortening of certain muscles, with 
the same distortions as before, unless the 
positions are constantly secured by mechani- 
cal means. While the paralysis itself does 
not directly produce the unequal distribution 



98 INFANTILE PARALYSIS, AND 

of force, its existence renders the patient 
liable, from slight and accidental causes, 
to all those changes in the condition of the 
muscles which were discussed in the first part 
of this essay. In short, whatever may be the 
apparent hopelessness of the paralysis, the 
only object in treatment should be to remove 
it as far as possible, and in the carrying out 
of this idea the mechanical appliances can ac- 
complish but the first step. 

SPECIAL MEANS OF DEVELOPMENT. 

The next thing to be attended to should be 
those means which directly tend to increase 
the nervous and muscular power of the 
affected member. And here we come back 
to the same remedies which are applicable in 
the first stages of the disease. We have 
labored long and patiently to imperfectly 
mend what, by proper management, might 
have been easily prevented, and now we 
begin our actual treatment. Our object is to 
increase the muscular power, and after the 



ITS ATTENDANT DEFORMITIES. 99 

great and, to a certain extent, irreparable 
loss in time, we should be prepared to 
be satisfied with moderate amelioration, when 
if the means had been applied in time 
they might have gone far toward securing 
complete restoration. Still, the stimulating 
effect of heat and the gentle use of the 
muscles without over-taxing them seem to be 
the true physiological means for increasing 
their irritability and power. 

And it is truly wonderful to what an extent 
the development may often be carried even 
in the worst cases. Indeed, there are few 
forms of distortion following infantile paral- 
ysis which are so bad that they can not be 
improved so as to afford the patient a service- 
able limb. But it takes time and patience. 

PARALYSIS OF UPPER EXTREMITIES. 

Paralysis of the upper extremities is of 
frequent occurrence ; and, incomprehensible 
as it would appear, on the theory that this 
form of paralysis arises from a lesion of the 



100 INFANTILE PARALYSIS, AND 

brain or spinal cord, in the larger number of 
cases, it is not accompanied by any paralysis 
of the lower portion of the body. There are 
cases of paralysis of the whole body and all 
extremities, or of one upper and one lower 
extremity. I have even seen a paralysis of 
the arm on one side accompanied with paral- 
3^sis of the opposite leg! Yet in the majority 
of cases the paralysis affects only one upper 
extremity. The paralysis of an upper extrem- 
ity is characterized by the same phenomena in 
all respects as when the disease affects a lower 
extremity. Wherever there is extension of 
a muscle, there we find the greatest weakness ; 
and, on the other hand, wherever the muscles 
have been relaxed, then they have "con- 
tracted" or become shortened. From the 
nature of the case, the deltoid is apt to 
especially suffer. The weight of the whole 
arm makes continuous traction upon the 
deltoid, and we consequently find that muscle 
almost invariably extended and atrophied to 
the last degree — fig. 18. At the same time, 



ITS ATTENDANT DEFORMITIES. 



101 



we are seldom troubled with serious muscular 
shortening, for the simple reason that the arm 
hangs in such a manner that no muscles are 
habitually relaxed ; but all the muscles, both 




Fig. 18. 

flexors and extensors, are weakened by con- 
tinuous stretching. For this reason, the 
paralysis of the arm, all other things being 



102 INFANTILE PAEALYSIS, AND 

the same, is relatively worse than of the 
lower extremities. There is seldom the same 
amount of paralysis in flexors and extensors, 
but the difference is generally that of different 
degrees of weakness, according as they have 
been subjected to different degrees of stretch- 
ing. The obliteration of the deltoid and the 
stretching of the ligaments and separation of 
the head of the humerus from the glenoid 
cavity is well shown in the cut. 

The treatment for paralysis of the arm 
must be the same in principle as for paralysis 
in the lower extremities, with modifications 
corresponding to the form of injury to which 
it has been subjected since the paralysis 
occurred. As the arm has not become dis- 
torted by being bent down by the weight 
above it, we have comparatively few deform- 
ities, and these are not characterized by the 
same degree of alteration in the osseous forms 
as in the joints of the legs and feet. But we 
have other difficulties equally formidable. 
All the joints are partially drawn asunder, 



ITS ATTENDANT DEFORMITIES. 103 

the articulating surfaces are smooth and 
rounded, and the muscles and ligaments are 
relaxed in many cases to the last degree. 

THE MUSCLES MUST BE RELIEVED OF TRACTION. 

There is one simple course to pursue. We 
must sustain the arm, and by thus relaxing 
the muscles, allow them to contract and regain 
somewhat of their impaired contractility. I 
have used with excellent effect a kind of sling 
that partially flexes the elbow, and sustains 
the whole arm so completely that the shoul- 
der-joint is closed and the deltoid completely 
relaxed. To this can be attached suitable 
appliances for any deformities of the hand and 
fingers which may exist. 

DEFORMITY OF HAND. 

The principal or most common difficulty of 
the hand arises from atrophy of the adductor 
muscles of the thumb. By the atrophy of 
these muscles the thumb is drawn back into 
the same plane as the fingers, and the ability 



104 



INFANTILE PARALYSIS, AND 



to adduct, flex, and oppose the other fingers 
and to grasp is entirely lost. The apparatus 
shown in fig. 19 is calculated to meet the 
difficulty. It is made of covered tin or zinc — 
gutta-percha will do — with the projection (a) 
to adduct and hold down the thumb ; the 




Fig. 19. 

strap (i) keeps it in position. With the 
thumb thus held opposite the fingers, the 
patient at once begins to make the hand useful 
in grasping and holding objects. This new 
power also hastens the muscular development. 



ITS ATTENDANT DEFORMITIES. 105 

The position of the thumb after atrophy of 
its adductors is well shown in fig. 18. 

The sustaining of the arm in the sling must 
be continued uninterruptedly for a very long 
time — it will be of no use unless kept up 
without intermission — and should be com- 
bined with suitable exercise of the muscles as 
fast as they begin to recover contractile 
power. But six months 7 suspension in the 
sling alone before the exercises were com- 
menced would, in many cases, be good treat- 
ment. 

The exercises should never consist of 
hanging or holding heavy substances ; on the 
contrary, gentle and light exercises should be 
adapted to the feeble muscles. 

HOW TO DETECT AND USE LATENT FORCE. 

Fig. 20 shows an admirable apparatus for 
exercising the deltoid muscle. So long as 
the weight of the arm exceeds by the smallest 
fraction the strength of the muscle, it will 
continue to be overpowered and utterly in- 



106 



INFANTILE PARALYSIS, AND 



capable of causing the slightest movement of 
the arm. And yet there may be within it 
a latent strength, only needing opportunity to 




Fig. 20. 

be shown and developed till it might be- 
come adequate to effect ordinary movements. 
Suppose the arm weighs ten pounds, and the 
deltoid could lift but five pounds — how is this 
latent force to be made available ? Simply 
by reducing the resistance to the muscle — 
that is, reducing the weight of the arm — to 



ITS ATTENDANT DEFORMITIES. 107 

three or four pounds, or to any amount less 
than the capacity of the muscle, when we 
should immediately witness a movement of 
the arm by action of this muscle. The weight, 
W, in the accompanying illustration, is moved 
to a point where it will just balance and 
neutralize so much of the weight of the arm 
as shall reduce the resistance to the capacity 
of the muscle. From this point we begin our 
development. As the strength of the muscle 
increases, less and less of the arm is balanced, 
till, by-and-by, the muscle becomes capable of 
raising the whole arm, and more. After that 
time the power in the muscle continues more 
than sufficient to accomplish motion. Other 
exercises, adapted to the action of the arm, 
forearm, wrist and fingers, must be employed, 
if we would have the development uniform. 
So of all actions of the various bodily mem- 
bers ; apparatus must be contrived with such 
complete adaptability, that the natural action 
of the joint may be secured together with 
most delicate measure of muscular force. 



108 



INFANTILE PARALYSIS, AND 




Fig. 21. 

Fig. 21 (like fig. 17, for the ankle) illustrates a lateral action at 
the knee. A rivet joint at A allows flexion and extension ; the 
lateral motion at B is secured by the key C, lengthening or 
shortening the side of the apparatus. In knock-knee, bow-leg, 
and other deformities of the lower extremitie , lateral action is 
indispensable. 



ITS ATTENDANT DEFORMITIES. 109 

Iii what has been said, I have aimed to 
illustrate principles, and hence have shown 
the most simple adaptation of apparatus. 
And as regarding deformities, I have avoided 
extreme cases, and have confined my observa- 
tions to such as, by following a consistent 
plan of treatment, may always reward our 
efforts with either cure or amelioration. 

CONCLUSION. 

The facts and arguments contained in the 
preceding pages may be summed up in the 
following propositions, viz. : 

1. Infantile Paralysis is an arrest of vegeta- 
tive development from some unknown cause. 

2. The characteristics of this form of paral- 
ysis suggest a peripheric blight rather than a 
loss of central nerve-power. 

3. With diminished nutrition, temperature 
and muscular power there is also diminished 
muscular irritability ; and there is no such 
thing as involuntary or reflex contraction in 
infantile paralysis. 



110 INFANTILE PARALYSIS, AND 

4. The shortening of certain muscles is not 
a necessary consequence of infantile paral- 
ysis ; and when it does occur, it is simply 
the adaptation of their length to the position 
they happen to be in. 

5. It is entirely accidental which muscles 
become shortened, whether flexors or ex- 

' tensors. 

6. Hence, deformities are not a necessary 
consequence of infantile paralysis, and when 
they are allowed to occur, the process of 
recovery is arrested. 

7. When deformities have already formed, 
they should be treated for an ultimate end — ■ 
viz., to bring the patient back to the place 
from which he should not have been allowed 
to diverge, where the treatment for his paral- 
ysis should begin. 

8. Hence, tenotomy and mechanical appli- 
ances are only means to an end — the first 
steps of a course of treatment having in view 
the restoration of the muscular power. 

9. The most natural means for this purpose 



ITS ATTENDANT DEFORMITIES. Ill 

is the supply of local heat — involving in- 
creased local circulation — together with local 
exercise corresponding with the position and 
ability of the part exercised. 

10. The element of time must also be taken 
into consideration. 

The following cases will still further eluci- 
date the foregoing views : 

Case 6. — T. T., aged two years and a half, 
was paralyzed while teething. Had had 
several attacks of sickness, but no diarrhoea ; 
was nervous and feverish. After lying altern- 
ately in his crib and in his mother's arms for 
three days, he seemed convalescing, when, 
one day, on attempting to make him stand, it 
was discovered that the right leg was paral- 
yzed. The next day his left arm was found 
to be also paralyzed. He at once began to 
improve, and in three weeks was able to push 
a chair about the room. In April, 1862, 
seven months afterward, I saw him. He was 
then a very active, nervous boy, but plump, 
ruddy, and rather precocious. At that time 



112 INFANTILE PARALYSIS, AND 

the hand was useless, and he walked badly. 
After six weeks 7 treatment the use of the arm 
and hand was fully restored. The leg and 
foot improved equally with the hand and arm. 
He had regained the use of the muscles, and 
could control all his motions ; but he left 
before he had regained enough strength in 
the ankle to support his weight, and there 
was some shortening of the tendo-Achillis 
with diminished action of the flexors — not 
enough power to lift the foot. He wore no 
apparatus at that time, for I had not then 
learned to anticipate and provide for the 
effects of the weakened flexors. Two years 
afterward he returned with a fully formed 
talipes varus, and complete loss of power in 
the flexors of the foot. Efforts to extend the 
muscle proving unavailing, the tendo-Achillis 
was divided, in the fall of 1863. Returning 
home after the operation, I did not see him 
for several months, and when he came back, 
I found that extension of the muscle had 
been carried too far; the tendo-Achillis had 



ITS ATTENDANT DEFORMITIES. 11<3 

been too much elongated. The result was, 
that the flexors of the foot had become in 
turn shortened and restored to active strength. 
Since then the chief treatment has been to 
reverse the effects of the too great lengthen- 
ing of the tendo-Achillis — that is, to overcome 
the flexors and increase the strength of the 
gastrocnemius ! 

The points of special interest in this case 
are the paralysis of one arm and leg on 
opposite sides; the arrest of cure and the 
formation of talipes after recovery had gone 
on so far ; and the transferring of the seat of 
shortened muscles from the posterior to the 
anterior side of the leg ! 

Case 7. — J. G., aged twelve years and five 
months. In March, 1865, had slight indis- 
position and loss of appetite, some fever, 
and headache occurring evening and morning, 
the latter increasing in severity as her 
strength diminished. Complained also of pain 
in the left leg. By the middle of April was 
much reduced, and had an attack of diptheria, 



114: INFANTILE PARALYSIS, AND 

from which she recovered in a few da3~s 
without any apparent change in the other 
symptoms. But from that time her previous 
unpleasant symptoms gradually lessened. She 
complained of pain in her back and legs, but 
gained in strength. About the first of June 
she began to try to walk ; but there was found 
to be considerable shortening of the tendo- 
Achillis of the left heel. She tried crutches 
without avail, and finally could only creep a 
little upon her knees. I first saw her on 
the 20th of November following the attack. 
At that time there was paralysis of both 
legs, nearly complete loss of power in the left, 
and shortening of the flexors of the thighs 
and legs and of the extensors of the feet ; the 
left foot particularly being extended nearly 
to a line with the leg. The extensors of the 
thighs and legs and the flexors of the feet 
were wholly powerless. All improvement 
which could have been of practical value had 
ceased, and she was apparently crippled for 
life. Believing that if the extended muscles 



ITS ATTENDANT DEFORMITIES. 115 

could be speedily relieved, there would be a 
further effort of Nature to resume the repar- 
ative process (unfortunately interrupted by 
the progress of the deformities), my attention 
was at first directed to extending the short- 
ened muscles. This was done by appropriate 
apparatus, and at the same time the muscles 
were brought into gentle use as fast as their 
action was made possible through liberating 
the motions. She at once began to improve, 
and in May following I had the satisfaction 
of seeing her walk erect and with the function 
of every muscle restored to her. The res- 
toration is quite complete. 

This case is related to illustrate the gradual 
and relatively prolonged course in the acces- 
sion of the disease, as often happens in older 
patients, and also to show the fact, that even 
in a patient of her age it was not known at 
w r hat time the paralysis occurred ; the arrest 
of the recuperative process after the muscles 
were allowed to lose their dynamic relations ; 
and the immediate resumption of recuperation 



116 INFANTILE PARALYSIS, AND 

when apparatus had restored them to their 
natural positions. 

Case 8. — This case is only interesting in 
consideration of the wide extent and com- 
pleteness of the paralysis in connection with 
the mild character of her symptoms ; and 
also, that even in so grave a case improve- 
ment is still steadily going on, though at a 
very slow rate. 

S. W., aged seven years, complained of 
some slight indisposition for two or three 
days ; she had some fever, and headache. A 
physician was called, who pronounced the 
symptoms of a typhoid character, and in a 
day or two she was found to be completely 
paralyzed from head to foot. This was in 
August, 1864. I saw her in May, 1865. At 
that time she had regained tolerable use of 
one hand ; but could neither stand nor sit, 
and the so-called contractions existed wher- 
ever circumstances had favored their occur- 
rence. Of course the power of their antago- 
nists was entirely gone. By proper apparatus 



ITS ATTENDANT DEFORMITIES. 117 

the deformities were reduced, the contractions 
overcome, and, as before stated, she has from 
that day steadily continued to gain. Although 
she can not yet walk, no deformity has 
occurred, nor can occur so long as the same 
principles of treatment are carried out. 

Case 9. — The interesting feature in the 
following case is the good degree of improve- 
ment in the muscular power as a direct result 
of the simple extension of the contracted 
muscles. The development of muscle would 
without doubt have been much greater if 
her treatment had also embraced the local 
exercises ; but in that case it would not have 
so well illustrated the views so often insisted 
on in these pages, that improvement is 
arrested long before it has reached its 
ultimate limit by positions which allow of a 
shortening of muscles ; and also, that some- 
times, as in this case, the process of recovery 
may be resumed and carried forward to a 
considerable extent years afterward, if the 
injured muscles are relieved by extending the 



118 INFANTILE PARALYSIS, AND 

shortened ones. In this case there was no 
power in the flexors of the foot and extensors 
of the leg during eight years; but they im- 
mediately regained a considerable degree of 
strength when the cause of the suspension 
of improvement was removed. Apparatus, 
shown in figs. 12 and 13, were furnished, 
with appropriate directions. As I had never 
seen the case but twice, and it had received 
no other treatment, I wrote to the father for 
the facts, which may as well be given in his 
own words : 

" My daughter Josie, who was placed tinder your 
care in May and November, 1865, and has at home 
followed your directions in wearing more or less 
apparatus adjusted to her partially paralyzed leg, 
first manifested to us that her leg was debilitated 
when about eighteen months of age. She walked 
when about a year old, then gave up walking. We 
attributed the fact to debility from teething. When 
she resumed walking, at about eighteen months of age, 
the weakness in one leg was discovered. We flattered 
ourselves she would outgrow it, having no suspicion 
of the real trouble. Her condition when you saw her 
in May, 1865, you can describe better than I can. 



ITS ATTENDANT DEFORMITIES. 119 

She was then nine years and nine months old. I can 
describe no symptoms except weakness in the leg; 
wasting of the flesh, reducing it to from one to one 
and a half inches in circumference below the size of the 
other; a constant liability to fall upon that knee, so 
much so that a pad was kept on it to prevent bruising ; 
an entire inability to go either up or down stairs by 
placing the weak foot or leg before the other. She also 
uniformly bore her weight on the other leg, and thus 
distorted her form. When she went to you, she could, 
bear her weight on that leg alone, but was powerless 
in the effort to kick with it, or to throw her foot in 
front without throwing out the whole limb, and could 
not approach toward a hop upon it. 

" She has since that time shown much improvement, 
sufficient to afford me much encouragement. She can 
hop on it feebly, raising herself by a hop on that foot 
about three inches perpendicularly without difficulty ; 
can throw out her foot in front, but not with much 
energy. Her lameness is still quite perceptible in 
walking, and still more so when running. She falls 
but seldom; her limb shows more hardness of muscle 
and fullness. The apparent projection of the knee-pan 
has to some extent diminished. 

"Yours, J. M." 



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